HSIB review into the lack of timely monitoring of glaucoma patients

Our response to the HSIB review of glaucoma monitoring, July 2019

Optometrist examining patients eyes

The Consultation

In July 2019, the Healthcare Safety Investigation Branch (HSIB) launched a review of glaucoma monitoring, following a case they investigated where a patient experienced sight loss as a result of delayed treatment. HSIB are now looking at the issue across the healthcare system.

We submitted a joint response with the Local Optical Committee Support Unit, which outlined the role extended primary eyecare services are playing in reducing pressure on hospital eye services. 

The AOP's response

As HSIB is aware, demand for eye health services is high and growing; ophthalmology was the hospital speciality with the highest number of outpatient appointments in 2017-181 and the ageing population, availability of new technology and treatments and public health challenges such as obesity and smoking, will only see demand rise.

The HSIB interim bulletin also notes that up to 22 people per month experience severe and permanent sight loss because of delayed or cancelled hospital appointments2. The All-Party Parliamentary Group on Eye Health and Visual Impairment published a report on capacity problems in hospital eye services in 2018 which said patients are being failed ‘on a grand scale’.

We note that the interim bulletin says previous guidance on follow-up appointments for glaucoma, from NICE and the National Patient Safety Agency, has not reduced the risks around timely monitoring of patients with glaucoma.

We agree with the analysis in the interim bulletin that the lack of hospital capacity for follow-up appointments is an increasing problem, and that capacity challenges need to be addressed in a sustainable way.

Primary care optical practices are able to provide a range of extended primary care glaucoma services which are proven to relieve capacity in hospital eye clinics and are more cost-effective than hospital treatment.

However, these services are currently commissioned on a patchwork basis around the country.

In reporting on this investigation, HSIB should highlight the scope for primary care optical practices to address capacity problems and recommend that services should be commissioned more widely.

How optical professionals in the community can monitor and manage glaucoma

Eye health professionals in primary care have the skills, expertise and equipment to manage a large proportion of patients – with glaucoma or other conditions – who are currently seen within the hospital eye service.

In some areas of the country, primary care eye health professionals already provide services over and above sight tests, which are known as extended primary eyecare services. These services are delivered under clinical management frameworks agreed by the Clinical Council for Eye Health Commissioning, which brings together all relevant stakeholders, including the Royal College of Ophthalmologists, the College of Optometrists, optical sector representative bodies and eye health charities. These include glaucoma services, as well as minor eye conditions services for conditions such as red eye and dry eye.

But due to the fragmented nature of commissioning in England these services are not comprehensively commissioned. 

We therefore provide below a few examples of extended primary eyecare services for glaucoma referral filtering and monitoring which are already helping to relieve pressure on hospital eye departments, and which we believe should be routinely available across England to address capacity problems in hospital eye services.

Clinical context

NICE guidelines recommend that where inner eye pressure of 24mmHg or more is recorded during a sight test, further tests, such as repeating visual field assessment and IOP measurements on another occasion, should be considered before referral to the hospital eye service3. However, these are outside the scope of a sight test, so it is only possible for these tests to be carried out in an optical practice where the relevant extended primary eye care service has been commissioned. 

The threshold for referring patients for further investigation was raised from 22mmHg to 24mmHg in November 2017. This is the point at which people are most ‘at risk’ of going on to develop chronic open angle glaucoma. There are approximately 1.8 million people in the UK with inner eye pressure between 22mmHg and 24mmHg, so the change was introduced to reduce what were perceived to be unnecessary referrals. Patients with pressures of 22mmHg or 23mmHg are reminded of the need to have regular sight tests to monitor their pressures.

The changes made in 2017 were welcome, but the current threshold for referral still captures a large cohort of patients with high intraocular pressures, but who are not at immediate risk of developing glaucoma.  NICE recommends case-finding in primary care and calls for glaucoma repeat readings (measures) and enhanced case-finding to reduce the numbers of false positive referrals and improve referral accuracy by allowing primary care practitioners to deliver a greater clinical work-up in optical practices. 

Following diagnosis many patients can be safely monitored in primary care whilst those with a higher risk of disease progression can receive specialist care within the hospital eye service in a more timely manner.

LOCSU resources provide the framework for service delivery in optical practice.

To avoid unnecessary referrals to hospital, LOCSU has developed pathways for commissioned services that enable optometrists to carry out additional tests to determine whether a patient should be referred to hospital, or retained in the community for monitoring by an optometrist. These services have a direct and immediate impact on demand for hospital eye services.

Glaucoma repeat readings and referral filtering services

These services enable optometrists to carry out additional tests in suspected glaucoma cases before making a referral decision, rather than immediately referring all patients with pressure of over 24mmHg to hospital. Patients are only referred if the clinical findings are repeatable and reliable. The current funding of the NHS sight test does not allow for these additional tests, so these services need to be commissioned by CCGs.

Data from LOCSU’s central data repository shows over 10,000 patients were seen within repeat reading services delivered in primary eyecare practices in 2017-18. Two thirds were fully managed within primary care who would otherwise have required an appointment within the hospital eye service. We believe that if the service was available across the whole of England, the number of patients with glaucoma and ocular hypertension who could be managed within optical practices would be vast, freeing up hospital eye services to deal with the most complex cases.

Glaucoma Repeat Readings Service  
Darlington, Durham Dales Easington and Sedgefield, North Cumbria, Northumberland Tyne and Wear and North Durham CCGs Data for 2017/18 illustrates that 80% of patients were fully managed in primary care saving 1614 hospital appointments across the North East and Cumbria.

Data for 2018/19 illustrates that 81% of patients were fully managed in primary care saving a total of 875 hospital appointments across the North East and Cumbria. The reduction in activity for this service follows the aforementioned NICE guideline change to the inner eye pressure threshold.

Ocular Hypertension (OHT) monitoring

NICE guidelines (NG81) defines Ocular Hypertension (OHT) as repeatable intra-ocular pressure of 24mmHg or over who have a normal optic nerve head and visual fields at most recent assessment. OHT is a very important risk factor for Chronic Open Angle Glaucoma (COAG). A commissioned community OHT monitoring service allows optometrists to monitor those patients who would otherwise require monitoring by hospital eye services.

Ocular Hypertension (OHT) Monitoring Service  
Darlington, Durham Dales Easington and Sedgefield, and North Durham CCGs  Data for the period 1/1/2018 – 31/12/2018 illustrates that the vast majority of patients have been managed in Community Optical Practice for this service. 7% (22 patients) required routine referral back into the Hospital Eye Service due to a change in clinical status. Overall, 286 Hospital appointments were saved.

This service was commissioned for a small cohort of low risk patients in year one. Following evaluation, the service will be extended with more patients transferred to the optometry service.

Integrated glaucoma monitoring services 

This service allows patients with stable glaucoma to be monitored in primary care, within an optical practice, rather than in the hospital setting. If there is a change in a patient’s clinical status, patients are referred into the hospital eye service.

Glaucoma monitoring service  
Basildon and Brentwood, Castle Point and Rochford, Southend and Thurrock CCGs [and this will soon be extended to Mid Essex CCG as well] Since January 2019, 5854 patients in South East Essex have been seen in a community optical practice for monitoring of their stable glaucoma.  

These patients would normally have been seen at the local hospital trust which can require driving up to 20 miles.  

Patient satisfaction for this service is high, with most saying it is more convenient to be seen locally.  

Optometrist-led glaucoma assessment – Manchester Royal Eye Hospital

Manchester-based consultant ophthalmologist Fiona Spencer noticed a change over her time practicing. When she was a trainee, patients were more likely to have lost vision when she saw them, whereas now more of a person’s sight can be saved. This is clearly a positive development, and a result of improved technology and treatment, but it has led to an increased workload5. In 2000, Fiona established a glaucoma pathway which includes an optometric clinic, which manages approximately 45 per cent of the caseload.

A recent patient satisfaction survey showed 96 per cent were happy with the service, and 52 per cent rated the service as good, or better than being seen by a consultant.

Other extended primary eyecare services

In this response we have concentrated on the value of services for patients with glaucoma, which is the focus of the HSIB investigation. To give additional context, optical practices can also provide other services which can relieve pressure on hospital eye departments, as well as other parts of the NHS, and should also be commissioned on a wider scale in order to address the capacity problems the HSIB has noted. 

For instance, an evaluation of a Minor Eye Conditions Service in Lambeth and Lewisham published in the British Medical Journal found the service demonstrated clinical and cost effectiveness, led to a reduction in hospital attendances and had high patient satisfaction. Using the neighbouring London borough of Southwark as a control, the service has been shown to be clinically effective.

Primary care optical practices should also be fully utilised in the cataract pathway to meet the NICE recommendations on referral and deliver post-operative care for patients who have had uncomplicated surgery. In Gloucestershire, the implementation of a post-operative cataract pathway in 2016 saw 1000 patients cared for by a primary care optometrist, which allowed nurses to be redeployed in the emergency eye service. 

LOCSU has a directory of all of the services that have been commissioned in the different LOC areas across England:

We hope the above examples provide evidence of how the current crisis in hospital eye departments can be alleviated by making greater use of optical professionals in the community. We would also be happy to share the clinical management frameworks for these services if that would be helpful.


  3. The guidelines state that referral should also be made where there are signs of optic nerve head damage or a visual field defect consistent with glaucoma.
  4. This figure is lower than expected, as not all patients with stable glaucoma in the area have been discharged from the hospital eye service due to administrative problems.
  5. Oral evidence to the APPG on Eye Health and Visual Impairment’s inquiry into capacity problems in hospital eye services: